Provider Demographics
NPI:1124775705
Name:JOHNSON, JAMES CLIFFORD (OTA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CLIFFORD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 VAIL RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HIAWATHA
Mailing Address - State:NJ
Mailing Address - Zip Code:07034-3119
Mailing Address - Country:US
Mailing Address - Phone:917-913-9853
Mailing Address - Fax:
Practice Address - Street 1:31 VAIL RD
Practice Address - Street 2:
Practice Address - City:LAKE HIAWATHA
Practice Address - State:NJ
Practice Address - Zip Code:07034-3119
Practice Address - Country:US
Practice Address - Phone:917-913-9853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09110200224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant